Treatment-resistant posttraumatic stress disorder: strategies for intervention

The mainstay of treatment for chronic posttraumatic stress disorder (PTSD) is a combination of psychotherapy and medication treatments. The first-line medications for PTSD are antidepressants, with two selective serotonin reuptake inhibitors (sertraline and paroxetine) currently Food and Drug Administration-indicated for PTSD. However, many patients do not have an adequate response to antidepressants, therefore, combinations with other antidepressants or with other classes of psychotropic medication are often utilized to enhance the therapeutic response. Other agents that have been used include mood stabilizers, anti-adrenergics, anxiolytics, and atypical antipsychotics. The heterogeneity of symptom clusters in PTSD as well as the complex psychiatric comorbidities (eg, with depression or substance abuse) further support the notion that combinations of medications may be needed. To date, there is a paucity of data to support specific strategies for augmenting antidepressants in PTSD. This review will address representative existing studies and discuss several potential pharmacologic strategies for patients suffering from treatment-refractory PTSD.     

Suicide in bipolar disorder: Risks and management

Bipolar disorders are prevalent, often severe, and disabling illnesses with elevated lethality largely due to suicide. Suicide rates average approximately 1% annually, or perhaps 60 times higher than the international population rate of 0.015% annually. Suicidal acts typically occur early in bipolar disorders and in association with severe depressive or mixed states. The high lethality of suicidal acts in bipolar disorders is suggested by a much lower ratio of attempts:suicide (approximately 3:1) than in the general population (approximately 30:1). Risk factors can help to identify patients at increased suicidal risk, but ongoing clinical assessment is essential to limit risk. Empirical short-term interventions to manage acute suicidal risk include close clinical supervision, rapid hospitalization, and electroconvulsive therapy. Remarkably, however, evidence of the long-term effectiveness of most treatments against suicidal behavior is rare. A notable exception is lithium prophylaxis, which is associated with consistent evidence of major (approximately 80%), sustained relative reductions of risk of suicides and attempts, and lower lethality (increased attempts:suicide ratio). Such benefits are unproved for other treatments commonly used to treat bipolar disorder patients, including anticonvulsants, antipsychotics, antidepressants, and psychosocial interventions. Applying available knowledge systematically, with close and sustained clinical supervision, can enhance management of suicidal risk in bipolar disorders patients.     

Identity in bipolar disorder: Self-worth and achievement

This article considers self and self-concept in bipolar disorder. Bipolar disorder, defined on the basis of manic symptoms, is a highly debilitating psychopathology. It is heavily grounded in biology but symptom course is still very responsive to psychological and social forces in the lives of persons who have the disorder. This review assumes an overall view of the self that is typical of personality psychology: self as traits, self as goals and aspirations, and ongoing efforts to attain those goals. In this review, we will discuss two different facets of self and identity in bipolar disorder. First, we review a body of goal pursuit literature suggesting that persons with bipolar disorder endorse heightened ambitions for attaining goals and recognition from others. Second, we will review multiple findings which suggest that among persons with bipolar disorder, self-worth depends on measurable success in an extreme way. We will consider how the intersection of these two themes may lead to unique identity challenges for people with bipolar disorder, drawing from self-report, behavioral, and neuroscience findings to critically examine this viewpoint.     

Religion and spirituality in the context of bipolar disorder: a literature review

Religion and spirituality (R/S) may play an important role for individuals with bipolar disorder (BD) by providing a means of coping with, and an explanatory model for, their disorder. We conducted a systematic review of empirical studies that have explored R/S in individuals with BD or samples that explicitly delineate individuals with BD. Only six studies met our inclusion criteria. Findings from these studies suggest that R/S strategies may be important for some people in the management of BD. Religion and spirituality thus become relevant concerns for a therapeutic regime that seeks to develop wellness within a bio-psycho-social model. However, the limited body of research and methodological shortcomings of existing research make it difficult to draw relevant conclusions about how this might be accomplished. The authors propose a need for longitudinal, prospective, mixed methods research in order to inform evidence-based practice.     

Gender differences in major depressive disorder and bipolar disorder

This paper reviews the literature on gender differences in major depressive disorder (MDD) and bipolar disorder (BPD). Beginning in adolescence, women are at a higher risk than men of becoming depressed. Avenues of investigation that might ultimately help to explain this phenomenon include studies of gender differences in the processing of emotional stimuli, the psychotropic effects of gonadal steroids, and environment/gene interactions in men and women. With the exception of the elevated suicide rate among men, consistent gender differences in the course and symptoms of MDD have not been found. In BPD, women are more likely than men to develop a rapid-cycling course. Gender differences in treatment response, particularly in regard to mood stabilizing medications, warrant further study.     

A psychoanalytic interpretation of bipolar disorder

Abstract

The author proposes viewing mania as a form of defense against the state of depression resulting from “narcissistic overidentification with the depressive object” (i.e., the object in relation to which the depressive state developed), rather than as a periodic rebellion against such an internalized object. An account of the analytic psychotherapy of a clinical case of bipolar depression serves to illustrate this point of view, linked to the author’s specific conception of the dynamics of depression.     

Family transactions and relapse in bipolar disorder

This study examined whether patient symptoms and relatives' affective behavior, when expressed during directly observed family interactions, are associated with the short-term course of bipolar disorder. Twenty-seven bipolar patients and their relatives participated in two 10-minute family interactions when patients were discharged after a manic episode. Results indicated that patients who showed high levels of odd and grandiose thinking during the interactions were more likely to relapse during a 9-month followup period than patients who did not show these symptoms during the family discussions. Relapse was also associated with high rates of harshly critical and directly supportive statements by relatives. Patients' odd thinking and relatives' harsh criticism were significantly more likely to be correlated when patients relapsed (r = .53) than when they did not relapse (r = .12). Results suggest that bipolar patients who show increased signs of residual symptomatology during family transactions during the post-hospital period are at increased relapse risk. The data also suggest that relatives of relapsing patients cope with these symptoms by increasing both positive and negative affective behaviors. Moreover, a bidirectional, interactional relationship between patients' symptoms and relatives' coping style seems to capture best the role of the family in predicting relapse in bipolar disorder.     

Social support and the course of bipolar disorder

The current study prospectively examined the impact of social support on symptom severity and recovery from episodes in bipolar disorder, both as a direct influence and as a buffer of life events. Fifty-nine individuals with Bipolar I disorder were followed longitudinally with monthly symptom severity interviews. Social support was measured by the Interpersonal Support Evaluation List and the Interview Schedule for Social Interaction, and life events were assessed using the Life Events and Difficulties Schedule. Individuals with low social support took longer to recover from episodes and were more symptomatic across a 6-month follow-up. Results suggest a polarity-specific effect, in that social support influences depression but not mania. Discussion focuses on theoretical implications of a series of polarity-specific findings within the field.     

Portability of a screener for pediatric bipolar disorder to a diverse setting

Robust screening measures that perform well in different populations could help improve the accuracy of diagnosis of pediatric bipolar disorder. Changes in sampling could influence the performance of items and potentially influence total scores enough to alter the predictive utility of scores. Additionally, creating a brief version of a measure by extracting items from a longer scale might cause differential functioning due to context effects. The authors of current study examined both sampling and context effects of a brief measure of pediatric mania. Caregivers of 813 youths completed the parent-reported version of the General Behavior Inventory (PGBI) at an academic medical center sample enriched for mood disorders. Caregivers of 481 youths completed the PGBI at a community mental health center. Caregivers of 799 youths completed 10 items extracted from the PGBI at a community setting. Caregivers of 159 youths completed both versions of the PGBI and a semistructured diagnostic interview. Differential item functioning indicated that across samples some items functioned differently; however, total observed scores were similar across all levels of mania. Receiver operating characteristic analysis indicated that the 10 extracted items discriminated bipolar disorder from nonbipolar behavior as well as when the items were embedded within the full measure. Findings suggest that the extracted items perform similarly to the embedded items in the community setting. Measurement properties appear sufficiently robust across settings to support clinical applications.     

Hooked on a feeling: rumination about positive and negative emotion in inter-episode bipolar disorder

Rumination has been consistently implicated in the onset and maintenance of depression. Less work has examined rumination in the context of bipolar disorder, especially rumination about positive emotion. The present study examined rumination about negative and positive emotion in interepisode bipolar disorder (BD; n = 39) and healthy controls (CTL; n = 34). Trait rumination about positive and negative emotion, as well as experiential and physiological responses to a rumination induction, was measured. Illness course was also assessed for the BD group. Results indicated that the BD group reported greater trait rumination about positive and negative emotion compared with the CTL group, though no group differences emerged during the rumination induction. For the BD group, trait rumination about positive and negative emotion, as well as increased cardiovascular arousal (i.e., heart rate), was associated with greater lifetime depression frequency; trait rumination about positive emotion was associated with greater lifetime mania frequency. These findings suggest that interepisode BD is associated with greater rumination about positive and negative emotion, which in turn is associated with illness course.     

Narrative identity in female patients with remitted bipolar disorder: a negative past and a foreshortened future

The present study examined narrative identity and subjective well-being in outpatients with remitted bipolar disorder (BD) and a healthy control group. Fifteen female outpatients with remitted BD and 15 healthy control participants identified past and future chapters in their life stories, gave their age for the beginning and end of each chapter, rated emotional tone as well as positive and negative self-event connections associated with the chapters, and for future chapters rated the probability of the chapter. The BD patients reported less positive emotional tone and self-event connections for past chapters, but not for future chapters. However, the patients did describe fewer future chapters with shorter temporal projection into the future, and reported lower probability of future chapters. These characteristics of chapters were related to lower subjective well-being. The study suggests that a more negative narrative identity with a foreshortened future perspective may contribute to lower subjective well-being in patients with BD.